Provider Demographics
NPI:1679708564
Name:NELSON, CHRISTA
Entity type:Individual
Prefix:MRS
First Name:CHRISTA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:FL
Mailing Address - Zip Code:32343-0292
Mailing Address - Country:US
Mailing Address - Phone:850-509-2018
Mailing Address - Fax:
Practice Address - Street 1:277 KNIGHTS ROAD
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:FL
Practice Address - Zip Code:32343-0292
Practice Address - Country:US
Practice Address - Phone:850-509-2018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL082371Medicaid